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What is Medicare?

Medicare is health insurance for people aged 65 or older, under age 65 with certain disabilities and any age with End Stage Renal Disease (permanent kidney failure). You must have entered the United States legally and have lived here for at least 5 years to be eligible for Medicare.

Medicare consists of four parts: Part A, Part B, Part C and Part D.

Original Medicare is administered by the federal government. Original Medicare has two parts: Part A and Part B.

Part A is hospital insurance that helps pay for inpatient care you get in a hospital, skilled nursing facility or hospice and for home health care if you meet certain conditions. Most people don't have to pay a monthly premium for Part A because they or a spouse paid Medicare taxes for 40 calendar quarters (10 years) while working in the United States. If you aren't eligible for premium-free Part A, you may be able to buy Part A if you meet one of these conditions:

  • Your 65 or older, you're entitled to or enrolling in Part B and you meet the citizenship or residency requirements
  • You're under 65, disabled and your premium-free Part A coverage ended because you returned to work. (If you're under 65 and disabled, you can continue to get premium-free Part A for up to 8.5 years after you return to work).

Many people are automatically enrolled in Part A. If you’re age 65 or older and you are not getting Social Security or RRB benefits yet (for instance, because you’re still working), you won’t get Part A and Part B automatically. You need to sign up for them by contacting Social Security Administration at 1-800-772-1213 or visit a local office. TTY users should call 1-800-325-0778. If you worked for a railroad, contact the RRB to sign up.

If you don’t sign up for Part A until after you’re first eligible, you may have to pay a penalty equal to 10% of the Part A premium, unless you’re eligible for a Special Enrollment Period. The 10% premium penalty applies no matter how long you delay Part A enrollment. You will have to pay the premium penalty for twice the number of years you could have had Part A, but did not sign up.

Part A Benefits and Costs

Part B covers medical services like doctors' services, outpatient care, home health services and other medical services. Part B also covers some preventive services. There is a monthly premium for Part B. The standard Part B premium for 2011 is $115.40. However, there is no Social Security cost-of-living adjustment in 2011. Therefore, most people with Medicare already enrolled in Part B in 2010, with income below $85,000 for an individual or $170,000 for married couples, will pay the same premiums in 2011 they are paying in 2010.

Many people automatically get Part B. If you collect benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). If you don’t want to keep Part B, you must follow the directions when you receive your Medicare card to let Medicare know you don’t want it. Otherwise, you will be charged the Part B premium.

If you do not enroll in Part B when you are first eligible, you may have to pay a late enrollment penalty to get it later. For each 12-month period you delay enrollment in Part B, you will have to pay an extra 10% of the Part B premium, unless you qualify for a Special Enrollment Period. An example of a Special Enrollment Period would be if you had coverage through an employer and did not need to enroll in Part B. In most cases, you will have to pay that penalty every month for as long as you have Part B. If you’re enrolled in Part B because you’re disabled and you’re paying a premium penalty, you no longer have to pay this penalty once you turn age 65.

There are three enrollment periods that allow you to enroll in Part B:

Initial Enrollment Period - You can sign up when you’re first eligible for Part B. For example, if you’re eligible for Part B when you turn 65, this is a 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you enroll in Part B during the first 3 months of your Initial Enrollment Period, your coverage start date is the 1st day of your birthday month. If your birthday is the first day of the month, your coverage begins on the 1st day of the prior month.

General Enrollment Period - If you did not sign up for Part A and/or Part B (for which you pay monthly premiums) when you were first eligible, you can sign up between January 1–March 31 each year. Your coverage will begin July 1. You may have to pay a higher premium for late enrollment.

Special Enrollment Period - If you did not sign up for Part A and/or Part B (for which you pay monthly premiums) when you were first eligible because you’re covered under a group health plan based on current employment, you can sign up for Part A and/or Part B as follows:

  • Anytime that you or your spouse (or family member if you’re disabled) are working, and you’re covered by a group health plan through the employer or union based on that work.
  • During the 8-month period that begins the month after the employment ends or the group health plan coverage ends, whichever happens first.

Usually, you don’t pay a late enrollment penalty if you sign up during a Special Enrollment Period. This Special Enrollment Period does not apply to people with End Stage Renal Disease. You may also qualify for a Special Enrollment Period if you’re a volunteer serving in a foreign country.

Note: If you have COBRA coverage or a retiree health plan, you don’t have coverage based on current employment. You’re not eligible for a Special Enrollment Period when that coverage ends.

Part C are Medicare Advantage Plans. These plans are offered by private insurance companies approved by Medicare. You must have both Part A and Part B to join one of these plans. The plans provide all of your Part A and Part B services and generally provide additional services. You usually pay a monthly premium, and co-payments that will likely be less than the coinsurance and deductibles under Original Medicare. In most cases, these plans also offer Part D prescription drug coverage. Costs and benefits vary by plan.

The different types of Medicare Advantage Plans are:

  • Health Maintenance Organization (HMO) Plans - A Medicare HMO Plan has a network of primary care doctors, specialists, hospitals and other providers that you must go to. Most plans require referrals to see specialists.
  • Preferred Provider Organization (PPO) Plans - A Medicare PPO Plan has a network of primary care doctors, specialists, hospitals and other providers that you may go to.You have the flexibility to go to any doctors, specialists, or hospitals that are not on the plan’s list, but it will usually cost more.
  • Private Fee-for Service (PFFS) Plans - Generally, you get care from any Medicare-approved provider such as a doctor or hospital who, before treating you, agrees to accept the Medicare Private Fee-for-Service Plan’s terms and conditions of payment. If your provider does not agree to the plan’s terms and conditions of payment the provider should not provide services to you except for emergencies, and you will need to find another provider that will accept the plan.
  • Special Needs Plans (SNP) - Plans for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions).
  • HMO Point of Service (HMOPOS) Plans - An HMO plan that may allow you to get some services out-of-network for a higher cost.
  • Medical Savings Account (MSA) Plans - A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.

You can enroll in a Medicare Advantage Plan every year during the Annual Election Period (AEP). In 2011 the Annual Election Period will begin on 10/15/2011 thru 12/7/2011. You can also enroll during your Initial Election Period (IEP) or if you qualify for a Special Election Period (SEP). To join a Medicare Advantage Plan, you must have Part A and Part B and live in the plan's service area.

Medicare Part D are prescription drug plans offered by private insurance companies and approved by Medicare. There are two ways to get Medicare prescription drug coverage:

  • Medicare Prescription Drug Plans - These plans (sometimes called "PDP's") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
  • Medicare Advantage Plans - You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called "MA-PD's."

To join a Medicare Prescription Drug Plan, you must have Medicare Part A or Part B. You must also live in the service area of the Medicare drug plan you want to join.

Extra help or low income subsidy (LIS) is a program that helps people with Medicare who have limited income and resources pay for Medicare prescription drug coverage. If you qualify for extra help, you will get help paying for your Medicare drug plan’s monthly premium, and for some of the costs you would normally pay for your prescriptions. The amount of extra help you get will be based on your income and resources. You can apply for extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Your Medicare choices are:

Original Medicare - Managed by the Federal government, it provides your Medicare Part A and Part B coverage. (You can choose to have either one, or both parts.) In addition to Original Medicare, you can enroll in a Part D plan for prescription drug coverage. You can also purchase Medicare Supplement Insurance or "Medigap" to cover the gaps in Original Medicare.

Medicare Advantage (Part C) - Medicare Advantage Plans are an alternative to Original Medicare and are only available through private insurance companies.

Note: Medicare Advantage Plans are not the same as Medicare Supplement Plans. You cannot have both, Original Medicare and a Medicare Advantage Plan.

Medicare Savings Programs are programs that help millions of people with Medicare save money each year. States have programs for people with limited income and resources that pay some or all of Medicare’s premiums and may pay Medicare deductibles and coinsurance.

A Special Election Period (SEP) allows you to make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, such as if you move or you lose other insurance coverage. These chances to make changes are called Special Enrollment Periods (SEP's). Rules about when you can make changes and the type of changes you can make are different for each SEP.

The Annual Disenrollment Period (ADP) is from January 1 thru February 14. It allows you to disenroll from your Medicare Advantage Plan, and switch to Original Medicare. If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form. During this period, you can’t switch from Original Medicare to a Medicare Advantage Plan. You can't change from one Medicare Advantage Plan to another. You can't change from one Medicare Prescription Drug Plan to another. You can't join, switch, or drop a Medicare Medical Savings Account Plan.

 

 

The Facts

The Insurers

Medicare Supplement Insurers
 

The States

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Alaska D.C. Iowa Michigan New Hampshire Oregon Utah
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